Arthroscopic knee surgery when over 50. Are there non-surgical options?
Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C
At our center we see a lot of patients who love to be active, play golf, tennis, pickleball. We also see patients who have demanding lines of work. Contractors, landscapers, jobs that require being on their feet all day. What these patients have in common is that they are entering middle age and they are starting to have some degenerative breakdowns in their knees.
What they also have in common is that they have reached a point that their knee braces, over-the-counter medications, ice packs and heating pads are not helping anymore. Even so, the morning or pre-activity workout will still include pre-emptive NSAIDs to keep swelling at bay and the knee brace to hold their knee together. When the knee brace no longer fits under work clothes, then sometime of sleeve or taping is used.
So this may be your story. You went to your doctor, got a referral for an orthopedist, had an x-ray, an MRI, some damage was seen, maybe it was an undescriptive type of damage, something was there and no one was really sure what it was or to what extent. You were prescribed stronger doses of the medications that you were already taking to see if that helps. But you are starting to think the NSAIDs are make you problem worse. You were sent to physical therapy and massage therapy to see if that helped.
Now you are at the point where you have to decide to:
a) Live with it until you can’t anymore.
b) Seek a surgical option.
c) Seek something more on the alternative, non-surgical side of medicine. Here your orthopedist may have even discussed stem cell therapy and platelet rich plasma therapy. We are going to discuss all these options below.
When I entered into my 50’s my knees started to give out on me. There went my golf game.
Here is a familiar story.
When I entered into my 50’s my knees started to give out on me. They started to become very painful and I had constant swelling. I was developing a bone on bone situation in my knees. I am an active guy, or I was. I used to play golf every second I could get myself out there. When I do play now, when my knees feel up to it, I have to use the cart because I can no longer walk the course. It is just not my knees anymore. It is also the weight I have been putting on. My doctors convinced me that if I had knee surgery, and I did, I had most of my meniscus removed last year, that the benefit would be reduced pain, and increase in my activity, and it would be easier for me to lose weight. Maybe that is what happens for other people. That is not what happened for me.
After the meniscus removal my knee hurt more, I became less active, I put on more weight and now my activity is reduced to what ever I can do in physical therapy as even everyday walking has become painful. Now I am being told to consider knee replacement. The knee replacement, so I am told, will reduce my pain and make me more active and I will be able to lose weight. Well that is why I had the arthroscopic surgery and it did not work out. Now I am exploring other options.
In our almost three decades of helping people with knee pain, this is the type of confusion we see in patients. What will help me? What will not help me? The treatments I thought would help did not. The things I am doing to try to stay healthy may be making me unhealthy.
We have a number of articles on our website that discuss topics of staying healthy trough knee pain. Here are some of them:
- What is the best diet for my knee pain?
- Your bad diet and weight is destroying your knees and will send you to a nursing home
- Obesity and osteoarthritis
- The evidence that cholesterol medication is sending you to knee replacement
I do not want to do an annual knee surgery
So how do we have healthy individuals, maintaining weight, no time to slow down, staying active getting frequent knee surgeries? May be here is how:
I am very active, golf, tennis, out in the ocean a lot. Water and snow ski. Two years ago I tore my meniscus. Silly injury, all I did was jump off a stair. That was in my left knee. My surgeon told me all the years of activity were beginning to take their toll. I had arthroscopic surgery, the doctor took out a piece of my meniscus that could not be repaired and everything felt fine. Then I few months later, I did the same exact thing to my right knee. A silly injury, believe it or not demonstrating to someone how I hurt my left knee. I was scheduled for another meniscus surgery.
Now I am concerned that will I have to have a surgery every year? Taking out bits and pieces of my knee until there is nothing left? I am very healthy, almost 60 year old. I do not want to keep doing this until I need knee replacements.
Research: For many patients who are over 50, arthroscopic meniscus surgery should not be offered. Instead patients should continue with nonoperative management until total knee replacement is unavoidable.
From many years there has been a controversy as to whether arthroscopic knee surgery should even be offered to middle age patients. Some patients may get into that situation where they have had numerous surgeries.
In December 2020, surgeons published a paper in the medical journal Arthroscopy (1). In this paper the doctors traced arthroscopic knee surgical outcomes over a 20 years period in patients who had the knee surgery between the ages of 50 – 70. Part of the research was to see how many of these patients who had the arthroscopy, had to have a total knee replacement anyway.
Here are the learning points of this research:
- The study included 289 patients aged at surgery between 50 and 70 years old with diagnosis of degenerative meniscal tear who underwent arthroscopic meniscectomy.
- Patients with more advanced knee problems, women, and older patients were at higher risk to need a knee replacement after arthroscopic meniscus surgery
- The doctors reported a 15.7% conversion rate at 20 years from arthroscopic meniscus to total knee replacement and an average time between surgeries of seven years.
- Further, patients over the ago of 60 who had a lateral meniscectomy and concurrent ACL reconstruction were at higher risk for poor clinical outcomes at 20 years follow-up.
- Therefore, if patients present negative predictor factors, (more advanced knee osteoarthritis, being older) the arthroscopic meniscus surgery should not be offered, continuing with nonoperative management until total knee replacement is unavoidable.
Well maybe arthroscopic meniscus surgery can be offered for some.
Sometimes we will get an email from some one who will tell us: “I went to (a well known, leading medical center, one of the best in the world,) and they told me they would do a knee surgery, but they did not know what type to offer and once we will do the surgery we are not sure of the outcome, we will have to see if it helps.”
We do see many patients who were told that their meniscus surgery may or may not help. Ultimately the only way to know was to have the surgery and see how it turns out.
Here is a study that was in the August 2019 issue of The American journal of sports medicine.(2)
Here are the learning points:
- There is controversy about the benefit of arthroscopic partial meniscectomy for degenerative tears and damage in middle-aged patients.
- The study wanted to determine outcome success in middle-aged patients with no or mild knee osteoarthritis who had either a degenerative meniscal tear or a traumatic tear.
Results: There were no meaningful differences in patient satisfaction or clinical outcomes between patients with traumatic and degenerative tears and no or mild osteoarthritis . Predictors of dissatisfaction with arthroscopic partial meniscectomy were female sex, obesity, and lateral meniscal tears. Our findings suggested that arthroscopic partial meniscectomy was an effective medium-term option to relieve pain and recover function in middle-aged patients with degenerative meniscal tears, without obvious osteoarthritis, and with failed prior physical therapy.
In other words, if you do not have degenerative arthritis developing, were not obese, had the meniscus tear on the outside, and were were a man. This surgery would be more successful for you a s a “medium-term option.” That is until your knee started to deteriorate further and you needed an “end-term option.” Knee replacement.
Let us point out again, many people have very successful arthroscopic partial meniscectomy procedures. These are the people that we do not see at our center. We see the people will less than successful outcomes.
Do people have an over expectation of what arthroscopic knee surgery can really do for their knee problem?
People in pain have a lot of whishes. They wish the pain will go away, they wish they can get back on with their lives, activity and work. They wish the surgery, or any treatment including the ones we offer, will work.
The middle-aged patient and meniscus surgery – surgeons cannot predict which patients will benefit and who will not benefit from meniscus surgery. Flipping a coin would work just as well.
In our companion article: Should I have meniscus surgery? Does arthroscopic meniscus surgery leads to knee replacement? We have more extensive discussions about realistic outcomes of arthroscopic knee surgery and non-surgical treatments for knee problems in the older patient. Here is a summary of portions of that article.
The question trying to be answered here is: “Will this surgery work for me?”
A March 2020 study in the British Journal of Sports Medicine (3) questioned whether experienced orthopedic surgeons could predict who would benefit from surgery for degenerative meniscus tears and who would not.
The researchers set up an experiment. Surgeons participating in this study were given 20 cases to examine. In each case, the surgeon was asked to predict the outcome of treatment for meniscal tears by arthroscopic partial meniscectomy and exercise therapy in middle-aged patients. The surgeons were also asked to predict the beneficial change in knee function in those patients they would recommend to surgery and those patients they would send to physical therapy or an exercise program.
The surgeons combined to examine and predict outcomes in 3880 knees. The results?
- Overall, 50.0% of the predictions turned out to be correct, the surgeons were able to predict 50% of the time which treatment would be of most benefit before treatment. The researchers of this study however noted – 50% correct would be no better than flipping a coin as it equals the proportion expected by chance.
- Experienced knee surgeons were not better in predicting outcome than other orthopaedic surgeons.
- Conclusions: Surgeons’ criteria for deciding that surgery was indicated did not pass statistical examination. This was true regardless of a surgeon’s experience. These results suggest that non-surgical management is appropriate as first-line therapy in middle-aged patients with symptomatic non-obstructive meniscal tears.
Here is a positive study on the benefits of meniscus surgery (4) in the middle-aged patient: In this study, doctors said that an arthroscopic partial meniscectomy is a good option for a medial meniscal tear in late middle-aged adults. For the best success, you need a proper diagnosis and excellent surgical technique. If you follow these two rules all the patients could get good clinical results, HOWEVER, “there are some patients with motion restrictions in the early stage after the operation.”
In other words, even if a patient received “a proper diagnosis and excellent surgical technique,” problems with motion restrictions in the knee developed early. Motion restrictions are probably not what a middle-aged patient is expecting as a result of their meniscus surgery.
Stem Cell Therapy, Platelet Rich Plasma Therapy and Prolotherapy
In this sections we are going to discuss the realistic expectation of what these three regenerative medicine techniques can do to help you avoid a surgery. These treatments will not benefit everyone. Our hope here is to present information to help understand the treatments.
For more information on the different types of injections for knee pain. Please see our article: What are the different types of knee injections for bone on bone knees
Stem cell therapy as a non-surgical alternative to arthroscopic knee surgery
Perhaps nothing is as misunderstood in the world of regenerative medicine injections as is misunderstood when it comes to stem cell therapy. Our website is filled with articles on stem cell treatments. We are going to present some summarized information as it relates to you.
I have no meniscus, will stem cell therapy grow one back?
NO. Stem cell therapy, as an injection in the doctor’s office, will not grow a meniscus from nothing. in our article Does stem cell therapy for knee meniscus tears and post-meniscectomy work?, we offer a lot of research, patient stories and clinical observations. To summarize that article here with learning points:
The reality of stem cell therapy
- It is important to note that we do not use stem cell therapy on every patient. In fact, we use stem cell therapy in very few of our patients. We find that other simpler and less costly regenerative medicine injection treatments can work just as well. This is explained below.
Over expectation of what stem cell therapy can do may lead to patient disappointment
- In many people who reach out to our office, we find that they have an unrealistic expectation of what stem cell therapy can and cannot do. For some people, stem cell therapy cannot, in one simple injection, repair and reverse years of degenerative damage. Many treatments may be necessary.
- If you have a meniscus tear, lesion, or hole in the articular cartilage, stem cell therapy may help create a natural healing patch, but, the treatment, like any medical treatment, has its limitations. Stem cell therapy can patch a hole, but without supportive treatments to address what caused the degenerative knee condition and what caused the hole in the cartilage in the first place, (knee instability and degenerative wear and tear motion from damaged and weakened knee ligaments), stem cell therapy will not be the single-shot cure a patient will hope for.
The research on stem cell therapy for meniscus tears. Does it work or not?
At our center, we have seen bone marrow aspirate stem cell therapy help many people. There are many types of stem cell therapy including Amniotic, cord blood, placenta stem cell therapy. We DO NOT USE THESE PRODUCTS. This is explained in our article: Amniotic, cord blood, placenta stem cell therapy.
October 2020 research: Bone marrow-derived mesenchymal stem cells have the potential to help form meniscus tissue
An October 2020 study (5) lead by the University of Alberta in Edmonton, Canada offered this observation in the journal Tissue Engineering (Part A). “Bone marrow-derived mesenchymal stem cells have the potential to form the mechanically responsive matrices of joint tissues, including the menisci of the knee joint.” Matrices are the scaffold-like structures that are created in the body for things like fingernails and cartilage to grow on.
In this study a comparison was made: Do bone marrow stem cells taken from the iliac crest (the wing of the pelvis) create meniscus matrices? Further, if they do, how do they compare with stem cells taken from meniscus fibrochondrocytes cells (cartilage cells) taken from meniscus tissue removed during a partial meniscectomy of non-osteoarthritic knees. The general results? Bone marrow-derived mesenchymal stem cells from the iliac crest produced better meniscus building block tissue better than meniscus tissue did.
Bone marrow aspirate – stem cell therapy and Prolotherapy
In our office, “Bone marrow aspirate” or stem cell therapy is used in conjunction with dextrose Prolotherapy. Prolotherapy is a non-surgical regenerative treatment that can stimulate natural healing repair in the knee. The goal of the treatment to rebuild tissue and provide stability to the knee. Stem cell therapy or Stem cell Prolotherapy is the combined use of your own harvested stem cells and dextrose Prolotherapy to treat the entire knee environment.
Not all meniscus tears and injuries (even those after meniscus surgery) require stem cell therapy to heal. We have documented in numerous studies that simple dextrose Prolotherapy has a 90% success rate in our office. However, for cases of the more advanced meniscus and related cartilage damage, our team of Prolotherapy practitioners may choose to use stem cell injections in combination with dextrose Prolotherapy to strengthen and stabilize the surrounding support structures of the knee.
Our published research on stem cell therapy combined with Prolotherapy
When we use bone marrow derived stem cells and Prolotherapy together:
Our 2014 study in the journal Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders, (6) we examined 24 adult patients who had a diagnosis of radiographic osteoarthritis (this was degenerative knee diseases which was seen and documented on an MRI) and had visited our chronic pain clinic in 2009 for Prolotherapy treatment to relieve their chronic pain. The results of our study have shown that a combined bone marrow stem cell Prolotherapy treatment regimen of injections to painful sites in and around the knee provided pain relief and improved joint function.
Paving the way for stem cell therapy success with Prolotherapy treatments
In the simplest terms, Prolotherapy is the injection of sugar water into a damaged joint. Prolotherapy injections work to heal damaged joints by stimulating nature’s healing and regenerative processes through inflammation. Prolotherapy does so by causing a controlled, specifically targeted inflammation that helps grow new ligament and tendon tissue.
Stem cell therapy is an injection of your own harvested stem cells. Stem cell therapy is typically utilized when we need to “patch” holes in cartilage and stimulate bone. We explore this option in patients when there is a more advanced osteoarthritis and a recommendation to a joint replacement has been made or suggested. Realistic expectation of treatments success should be made during discussions with the providers office prior consultation.
Here are the case histories of this study:
Case history 1
- Patient is a 69-year-old male presented with pain in both knees.
- 4/10 on the left (30% frequency) and 7/10 on the right (90% frequency).
- Pain had begun years earlier while playing rugby and had been more severe for the four years prior to first office visit
- Pain resulted in frequent sleep interruption and limitation of exercise. Slight flexion limitation was noted.
- The patient was diagnosed with osteoarthritis and received five bone marrow/dextrose treatments at two month intervals in both knees.
- Two months after the final treatment, the patient reported that he was completely free of pain or stiffness in both knees, had regained full range of motion, no longer suffered sleep interruption, and was no longer limited in exercise or daily life activities.
Case history 2
- Patient is a 56-year-old male presented with pain in both knees.
- The patient is a former competitive weightlifter who continues to do strength training exercise.
- He complained of instability in both knees during exercise, as well as sleep interruption.
- The patient received 29 bilateral dextrose prolotherapy treatments over five years to the knee. At the final prolotherapy visit, sleep interruption was still present, pain intensity was 4/10, and pain frequency was 100%.
- Four months later, the patient was treated with platelet-rich plasma. Three months after plasma treatment, the patient began a series of three bone marrow stem cell injection treatments (without dextrose prolotherapy) at 2–3 month intervals. At the time of the second bone marrow stem cell injection treatments, stability was improved.
- At the time of the third treatment, pain intensity was 2/10 and pain frequency was 30%. Sleep was no longer affected. These gains were maintained for nine months.
Case history 3
- Patient is a 69-year-old female with pain in both knees.
- She had been previously diagnosed with osteoarthritis, had arthroscopic surgery to both knees eight years earlier, and bilateral medial meniscus surgery 15 years earlier.
- Pain occurred climbing or descending stairs and with standing or walking for two hours. Pain interrupted sleep and limited participation in racquet sports and golf.
- Pain intensity was 4/10 in the left knee and 5/10 in the right.
- The patient received six bilateral treatments with dextrose prolotherapy over a ten month period. After the first month of this period, the patient reported uninterrupted sleep, pain intensity of 2/10, resumption of limited golf, and an overall improvement of 50%–55%.
- One year after the final prolotherapy, pain intensity had returned to 4/10 with a frequency of 20%, and sleep interruption had resumed. At this time, the patient received the first of two bone marrow stem cell injection treatments with dextrose Prolotherapy treatments, five months apart.
- At the time of the second treatment, pain intensity was 1/10 with a frequency of 20%, sleep interruption was reduced by half, and patient-reported overall improvement was 90%. Eight months following the final treatment, the patient reported being free of pain and able to resume full participation in all of her usual athletic activities.
In Comprehensive Prolotherapy, the knee joint instability is restored by repairing and regenerating tissue
We use non-surgical treatments for meniscus tears. We may use our Prolotherapy treatments and PRP. This is an in-office injection treatment. This video and the summary below is an introduction to our non-surgical treatments. It is presented by Danielle R. Steilen-Matias, MMS, PA-C.
- Dextrose Prolotherapy is a simple sugar injection into the knee that attracts you own healing repair cells into the area to fix the damaged meniscus
- In some patients, it may not be enough to attract your own cells to this damaged area with Prolotherapy, in this type case we may have to put cells there via injection. Our first option would be Platelet Rich Plasma (PRP) Prolotherapy. This would put the healing factors found in your blood platelets into the damaged joint.
- WE DO NOT offer PRP as a stand-alone treatment or injection. While PRP brings healing cells into the joint, it acts to repair degenerative damage. In our experience, while PRP addresses damage deep in the such as a meniscus, we must still address the joint instability problem created around the knee. We do this with Prolotherapy. Here damaged or weakened ligaments that are simply “stretched,” can be strengthened with treatment to help restore and maintain normal joint mobility. We discuss the meniscus interaction with the MCL in a moment. Simple PRP on the inside, Prolotherapy on the outside of the joint.
- PRP is injected at the meniscus with ultrasound guidance
- Most meniscal tears require four to six treatments although that could be less or more depending on the patient.
- What helps our success rate with meniscal tears is our treatment of the MCL or the medial collateral ligament at the same time.
- We will use of ultrasound machine to access the integrity of the MCL
Platelet Rich Plasma Therapy and Prolotherapy, which stimulates tendons, ligaments, and cartilage to heal, has many advantages over arthroscopy, which include:
- These treatments are considered a much safer and conservative treatment
- the procedure does not take long to administer; an individual is usually in and out of the doctor’s office in less than an hour
- it stimulates the body to help repair the painful area; for example, the new collagen tissue formed is actually stronger than it was before the injury
- it reduces the chance of long-term arthritis; with arthroscopy, the chance of long-term arthritis increases
- in the case of athletes, it increases their chances of being able to play their sports for the rest of their lives; arthroscopy significantly decreases those chances
- exercise is encouraged while getting Prolotherapy treatments; one must be very cautious with exercise after arthroscopy
- the procedure is much less invasive; remember that arthroscopy requires the knee to be blown up with about 100 ml of fluid to fit all the scopes into the knee.
Do you want to ask about your knees? Get help and information from our Caring Medical staff
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